Healthcare Provider Details

I. General information

NPI: 1447211305
Provider Name (Legal Business Name): MOHAMMAD JAVAD IQBAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 07/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 WOODLAND DRIVE SUITE 110
ELIZABETHTOWN KY
42701
US

IV. Provider business mailing address

PO BOX 2636
ELIZABETHTOWN KY
42702-2636
US

V. Phone/Fax

Practice location:
  • Phone: 270-769-3631
  • Fax: 270-769-3996
Mailing address:
  • Phone: 270-769-3631
  • Fax: 270-769-3996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number18016
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: